Introduction Of Catheter Research Articles

Advancements in Imaging for Atrial Fibrillation Ablation: Is There a Potential to Improve Procedural Outcomes?

Since the introduction of atrial fibrillation (AF) ablation in the 1990s, the procedure has continuously evolved, with gradual improvements in outcomes and safety. Recent technological advancements include the introduction of contact force catheters and high-resolution electroanatomical mapping systems, while imaging modalities including transesophageal echocardiography and fluoroscopy have become integral parts of AF ablation procedures. Further, intraprocedural intracardiac echocardiography and the integration of cardiac magnetic resonance and computed tomography images with electroanatomical mapping have shown promise to improve procedural outcomes by reducing radiation exposure and procedural times. However, available data on procedural utility and the reduction in AF recurrence rates associated with these modalities are mixed. This review therefore aims to discuss the current common imaging modalities used in AF ablation and their potential impact on outcomes. In particular, imaging is discussed with respect to the important information it offers before, during, and after the procedure. Perspectives on the future of imaging in AF ablation are also shared.

Measurement of the Hepatic Venous Pressure Gradient and Transjugular Liver Biopsy.

Here we provide a detailed protocol describing the clinical procedure of hepatic venous pressure gradient (HVPG) measurement in patients with advanced chronic liver disease followed by an instruction for transjugular biopsy. Under local anesthesia and ultrasound guidance, a catheter introducer sheath is placed in the right internal jugular vein. Usingfluoroscopic guidance, a balloon catheter is advanced into the inferior vena cava (IVC) and inserted into a large hepatic vein. Correct and sufficient wedge position of the catheter is ensured by injecting contrast media while the balloon is blocking the outflow of the cannulated hepatic vein. After calibrating the external pressure transducer, continuous pressure recordings are obtained with triplicate recordings of the wedged hepatic venous pressure (WHVP) and free hepatic venous pressure (FHVP). The difference between FHVP and WHVP is referred to as HVPG, with values ≥10 mm Hg indicating clinically significant portal hypertension (CSPH). Before removing the catheter, pressure readings obtained in the IVC at the same level, as well as the right atrial pressure are recorded. Finally, a transjugular liver biopsy can be obtained via the same vascular route. Different systems are available; however, core biopsy needles are preferred over aspiration needles, especially for cirrhotic livers. Again, under fluoroscopic guidance a biopsy needle introducer sheath is advanced into an hepatic vein. Next, the transjugular biopsy needle is gently advanced through the introducer sheath: (i) in case of aspiration biopsy, the needle is advanced into the liver parenchyma under aspiration and then removed quickly, or (ii) in case of a core biopsy, the cutting-mechanism is triggered inside the parenchyma. Several separate passages can be safely performed to obtain sufficient liver specimens via transjugular biopsy. In experienced hands, the combination of these procedures takes about 30-45 min.

Hemodynamic Characterization Of Pulmonary Artery Hypertension In A Rat

Introduction: Hemodynamic characterization of Pulmonary Artery (PA) hypertension helps to reveal progression of disease of pulmonary vasculature with constrictive remodeling of pulmonary arterioles, leading to right ventricle (RV) dysfunction and right sided HF failure. In this preclinical methodology article, surgical access, controlled mechanical ventilator set up and direct open chest measurements of PA hypertension is described, employing a rat model. Chronic PA injury was induced by single dose of monocrotaline (MCT).
 Methods & Aims: Setting of controlled mechanical volume ventilation (CMVV) was adjusted to limit its influence on RV preload and LV afterload in the instance of chronic pulmonary disease. Volume-ventilation setting of tidal volume and respiration rate was based on body weight. Isoflurane monoanesthesia was used without any premedication. PA pressures were compared using single and dual pressure catheter at 3-weeks post injury. Initially, single pressure catheter was positioned in the PA to assess data quality, while advanced data comparison (RV and PA pressures) during PA hypertension were made using dual pressure catheter. PA access was performed using “high” RV needle-stab, adjacent to the anatomical area of the PA outflow.
 Results: Introduction of single pressure catheter was successful and collected data during RV systole and diastole did not produce any major pressure artefacts. Final position in the main PA was guided by using visual cues i.e. distance of pressure sensor on the catheter, accompanied by simultaneous data recording from that location. In case of dual pressure catheter, RV and PA pressure data were successfully collected. During PA hypertension, systolic ranges were (41-52 mmHg) vs. naive (25-30 mmHg); diastolic (21-27 mmHg) vs. (9-14 mmHg); n=4. In PA hypertension, high afterload pressures complicated RV ejection, with PAP cresting about 1mmHg higher than the maximal RVP. During further assessment, RV ejection was complicated by higher PA dicrotic notch pressures, at the end of systole; for hypertension (37-41 mmHg) vs. naïve (16-21mmHg), n=4.
 Conclusions: This study revealed that good rat pressure data could be collected from the main trunk of PA using an open chest supported by CMVV. In future, hemodynamic influence of respiratory pump in close chest setting and its influence on chronic PA hypertension needs to be analyzed using solid state pressure catheter. To accomplish this, pressure catheter design should be based on rat’s RV and its outflow anatomy.

Bougie through Murphy’s Eye During Airway Exchange: A Near Miss

AbstractEndotracheal tube (ETT) exchange is a common procedure performed in the operating room and intensive care unit for the purpose of changing damaged or soiled ETT with appropriate one. The exchange procedure is performed over an airway exchange catheter or ETT introducer (bougie). We report an event during ETT exchange over bougie wherein the introducer exited through Murphy’s eye. Here, we intend to re-emphasize the safety concerns pertaining to the use of bougie (with coude tip) as airway exchange conduit and enumerate the precautions to be taken during tube exchange.

P1449Anti-thrombotic management for electrophysiological procedures: results of the European Heart Rhythm Association (EHRA) young investigators survey

Abstract Funding Acknowledgements none Background Electrophysiological studies (EPS), with or without ablation, require percutaneous introduction of catheters into the heart to record local electrical activity. Instrumentation of catheters within the blood causes activation of the clotting cascade, increasing the risk of thrombus formation. To date, the electrophysiological community lacks international guidelines on the use of anti-thrombotic therapies before, during and after EPS. Purpose To survey the current practice regarding the use of anti-thrombotic therapies across member countries of the European Heart Rhythm Association (EHRA). Methods The survey was conducted in February 2019. Electrophysiologists from EHRA member countries were contacted to complete the survey by e-mail, utilizing the EHRA Young EP network. They were asked to answer a questionnaire containing information on anti-thrombotic and anticoagulation management before, during and after left-sided EPS and ablation: atrial tachycardia (AT), accessory pathway (AP) and ventricular tachycardia (VT). Results We obtained 41 answers responses from 40 centers in 15 European EHRA member countries. Regarding of antiaggregation, the most used antiplatelet is aspirin (100% before, during and after ablation). The most used anticoagulant was novel oral anticoagulants (NOAC) before ablation (47.1%), during hospitalization (85.2%) and at discharge (70.3%). The administration of anti-thrombotic therapy depended on the procedure time only in 10 cases (24.4%). For AP, before ablation, only 4 centers (9.7%) administered anti-platelets and 2 (4.9%) anticoagulants. During ablation, heparin was used by 85.4% of respondents maintaining ACT target 300-350 s in 36.6% of cases. At discharge, antiaggregation therapy was prescribed by 22 colleagues (53.7%) and anticoagulation only by one (2.4%). In patients with AT, before ablation, antiaggregation prophylaxis was prescribed by only 4 centers (19.5%) and anticoagulation by 11 (26.8%). During procedure, almost all centers (40, 97.6%) used heparin with ACT target 300-350 s in 58.5% of cases. At discharge, antiplatelet therapy was recommended by 12 colleagues (29.3%) and anticoagulation by 24 (58.5%). Regarding VT, before procedure, 8 centers (19.5%) prescribed antiaggregation and 5 (12.2%) anticoagulation prophylaxis. During ablation, all centers used heparin, maintaining ACT target 300-350 s in 58% of cases. The use of antiaggregation or anticoagulation depended on the left ventricle (LV) access in 15 centers (37.5%) and on LV ejection fraction in 11 (26.8%). At discharge, anti-thrombotic therapy was recommended by 16 colleagues (39%) and anticoagulation by 13 (31.7%). Conclusion Our survey showed that there is considerable variation in the management of anti-thrombotic therapy surrounding left-sided EPS and ablation. Further studies are necessary to evaluate the right approach to these procedures.

Incidence and Potentially Modifiable Risk Factors for Venous Thromboemblism Post Lung Transplant

Venous thromboembolism (VTE) is a frequent complication after lung transplantation. Most VTE occur within 30 days of surgery and consist primarily of upper extremity deep venous thrombosis (DVT). Prior studies have described incidence rates of up to 43%, which is much higher than in other solid organ transplantation. VTE after lung transplantation has been associated with a lower survival post-transplant. Due to the morbidity and costs incurred by this complication, modifiable post-operative risk factors must be identified to improve our outcomes after lung transplantation. Retrospective study population of patients who received a lung transplant at Temple University Hospital, Philadelphia, between 2017 and 2018 (n=197). We collected baseline demographics, laboratory values, intra-operative variables, as well as post-operative care measures such as central line days, pulmonary artery catheter days, days to physical therapy, initiation timing and interruptions in pharmacologic prophylaxis. The primary outcome was VTE event within one year of lung transplantation. 197 lung transplants were performed (R: 73 L: 70, double: 54) with a mean age of 65.5 years, most common indications were IPF (53%) and COPD (32.5%). The incidence of VTE within one year of transplant was 23.5% (n=47), most of which occurred within 30 days of transplant (72%). Most patients had upper extremity DVT (55%) and was treated with systemic anticoagulation (83%). Patients who had VTE after transplant tended to have a higher BMI (p=0.0048) and oxygen requirement (p=0.028) pre-operatively. Patients with VTE had a longer duration of Swan-Ganz catheter (p=0.0145) and the introducer catheter (p=0.0092). VTE patients had a longer time to physical therapy (p=0.06) and time to ambulation (p=0.0471) post-surgery. On multivariate analysis, interruptions in pharmacologic VTE prophylaxis within the first five days post-operatively was the only modifiable risk factor identified (OR, 4.123, % CI, 1.642-10.352, p=<0.0001). Unlike previous studies, we did not find an association between VTE post-transplant and a history of prior VTE, LAS score, diabetes, or age. Any interruption in DVT prophylaxis early post-transplant is a significant "modifiable" risk factor for development of VTE. Every effort should thus be made to avoid any interruption in prophylaxis.

ELECTROANATOMICAL MAPPING OF LEFT VENTRICULAR SCAR IS INSENSITIVE TO SUBENDOCARDIAL SCAR ON THICK WALL

Over the past decade, there have been tremendous advances in electroanatomical mapping (EAM) technologies, including introduction of multielectrode catheters for high-resolution mapping of scar. While EAM may not be suitable for detecting mid-wall scar, it has been assumed that these are capable. We

The history of bone marrow in orthopaedic surgery (part I trauma): trepanning, bone marrow injection in damage control resuscitation, and bone marrow aspiration to heal fractures.

One of the oldest procedures performed by man is trepanning of the bone and yet it was only in the last 40years that bone marrow aspiration has been used to treat nonunion disorders. These advances were possible due to improvements in instruments and in techniques to make holes in the bone, an history that began with skull trephinations around 8000-10,000years ago, and continued with sternum bone marrow injection for trauma resuscitation in the beginning of the twentieth century; this procedure had improved at the beginning of the twenty-first century to allow pelvis bone marrow aspiration for the treatment of nonunion. Trephined skulls from antiquity have been found in many parts of world, showing that trephining was ancient and widespread. Beginning with Neolithic period and the pre-Columbian Andean civilizations, the authors have traced the development of this surgical skill by describing the various surgical tools used to perform holes in the skull. These tools (trephines or trepan) were proposed at the end of the nineteenth century to study the bone marrow. At the beginning of the twentieth century, the sternum became the center of interest for the "in vivo" study of the bone marrow and the fluid injection in the sternum's bone marrow was described for resuscitation from shock during the World War II. With the introduction of plastic catheters and improved cannulation techniques, the need for intraosseous infusion as an alternative route for intravenous access diminished and sometimes abandoned. However, during the mid-1980s, James Orlowski allowed renaissance of the use of intraosseous infusion for paediatric resuscitation. Since then, this technique has become widespread and is now recognized as an alternative to intravenous access in adult emergencies; particularly, the intraosseous access has received class IIA recommendation from the Advanced Trauma Life Support program supported by the American College of Surgeons Committee on Trauma and bone marrow infusion is now recommended for "Damage Control" resuscitation. Although the pelvis bone contains half of the body's marrow volume, it was only in 1950 that the pelvis was proposed as a source for bone marrow aspiration and bone marrow-derived mesenchymal stem cells to improve healing of fractures. It will be many years before doing holes in the bone as orthopaedic trauma procedure will be relegated to the annals of history.

A comprehensive review of the diagnosis and management of mitral paravalvular leakage.

Mitral paravalvular leaks (PVLs) commonly occur in patients with prosthetic valves. Paravalvular defects may be clinically inconsequential and may aggravate hemolysis or cause heart failure through regurgitation. Accordingly, patients may eventually require intervention such as redo surgery or a transcatheter closure of the defects. The introduction of purpose-specific closure devices and new steerable catheters has opened a new frontier for the transcatheter PVL closure. This mode of treatment is an initial therapy in most centers with experienced structural heart team. However, head-to-head data comparing two treatment modalities (surgery and transcatheter closure) are limited, and the world-wide experience is based on nonrandomized studies. Multimodality imaging, including three-dimensional transesophageal echocardiography, facilitates the delineation of mitral PVLs and provides essential data that aids the communication between the members of the structural heart team. In the near future, the success of interventional therapies will most probably increase in patients with mitral PVLs with the introduction of hybrid imaging modalities (echocardiography, cardiac computed tomography, and fluoroscopy). In conclusion, this paper summarizes the etiopathogenesis, clinical characteristics, diagnosis, and treatment of mitral PVLs. (Anatol J Cardiol 2020; 24: 350-60)

Physician Reimbursement for Vascular Surgery Procedures and Vascular Laboratory Studies Before and After the Affordable Care Act

The Patient Protection and Affordable Care Act (ACA), fully implemented by 2015, has significantly increased the number of Americans with health insurance. However, its impact on physician reimbursement (PR) is not well studied. Our objective was to determine the ACA's impact on the professional component of PR for selected vascular surgery (VS) procedures and vascular laboratory (VL) studies at our institution. PR for the following five VS procedures and three VL studies were obtained from our billing department: CPT 34803 (endovascular aneurysm repair), 35301 (carotid endarterectomy [CEA]), 35656 (lower extremity bypass [LEB]), 36010 (introduction of catheter into vena cava), 35200 (introduction of catheter into aorta [ICAo]), 93922 (ankle-brachial index), 93925 (lower extremity arterial duplex ultrasound), and 93970 (lower extremity venous [LEV] duplex ultrasound). The data were organized by payer: Medicare, Medicaid, commercial insurers (CIs), and other. PR was studied before the ACA (January 2008-December 2009) and after the ACA (January 2015-December 2016). The post-ACA PR and insurance-adjusted reimbursement (IAR) in 2016 dollars using the Consumer Price Index were calculated and compared using one-sample t-test. The percentage difference between the post-ACA PR and IAR was also compared. PR for 1704 VS procedures and 18,904 VL studies was analyzed. The post-ACA PR was significantly lower than the IAR for most Medicare procedures (CEA, LEB, and ICAo) and Medicaid procedures (CEA, LEB, introduction of catheter into vena cava) and for ICAo for all payers. The post-ACA PR was significantly higher than the IAR for ankle-brachial index for all payers; lower extremity arterial duplex ultrasound for Medicare, other, and CIs; and LEV duplex ultrasound for Medicaid and CIs. Only Medicare LEV duplex ultrasound had post-ACA PR that was significantly lower than IAR (Table). The percentage differences for VS procedures were mostly negative for the Medicaid and Medicare groups but were more varied in the CIs and other payer groups (Fig). In comparing reimbursement before and after ACA implementation, PR for most VS procedures has not kept up with inflation. However, for most VL procedures, PR has exceeded inflation. Further efforts are needed to support VS reimbursement, including higher valuation of the Medicare conversion factor.TableComparison of post-Affordable Care Act (ACA) reimbursement and insurance adjusted reimbursement (IAR)InsurancePost-ACA reimbursement, $IAR, $P valueCPT 34803, EVARMedicare1283.511174.92<.001Medicaid1141.831108.47N/AaOther1687.691126.51.659Private1720.491643.54.927CPT 35301, CEAMedicare1119.721300.93<.001Medicaid1033.181342.13.007Other1337.141315.60.912Private1817.951753.01.423CPT 35656, LEBMedicare947.811257.25<.001Medicaid963.371363.13<.001Other693.361258.27.248Private1713.051792.02.732CPT 36010, ICVCMedicare71.1280.22.444Medicaid67.3193.76.045Other457.03152.81.424Private146.99148.32.945CPT 36200, ICAoMedicare112.01185.09<.001Medicaid84.98172.73<.001Other255.14155.00.022Private208.36268.73<.001CPT 93922, ABIMedicare24.6011.74<.001Medicaid25.0711.10<.001Other31.0416.90<.001Private53.1122.47<.001CPT 93925, LEA duplex ultrasoundMedicare79.1940.43<.001Medicaid54.2336.18.298Other141.9234.24.014Private138.0454.94<.001CPT 93970, LEV duplex ultrasoundMedicare35.8246.41<.001Medicaid47.2830.17<.001Other43.9346.08.386Private93.3466.04<.001ABI, Ankle-brachial index; CEA, carotid endarterectomy; EVAR, endovascular aneurysm repair; ICAo, introduction of catheter into aorta; ICVC, introduction of catheter into vena cava; LEA, lower extremity arterial; LEB, lower extremity bypass; LEV, lower extremity venous; N/A, not applicable.aNumber too low for statistical calculation. Open table in a new tab

Peel-Away Catheter Introducer Sheath for Reducing Nasal Traumatic Injury During Pediatric Endoscopic Skull Base Surgery

Pediatric endoscopic endonasal surgery represents a still-growing discipline to approach complex skull base lesions and is characterized by unfavorable anatomical conditions. Children have very small nostrils and narrow rhinosinusal corridors, which could lead more easily to accidental injury to the nasal structures. We describe the use of a peel-away catheter introducer sheath as an innovative and minimally invasive technique to further reduce surgical trauma tothe nasal mucosa and structures in pediatric rhinoneurosurgery. From January 2009 to December 2018, the peel-away sheath technique was used in 6 pediatric endoscopic procedures for biopsy and/or removal of skull base tumors. The endoscopic technique with the use of the peel-away catheter allowed clear visualization of the surgical field during the whole course of the procedure and good surgical maneuverability. The use of the peel-away sheath did not prolong the surgical operation time and provided a good working channel. No intraoperative or postoperative major complications were observed. No nasal short-term complications were registered in all patients. The use of a peel-away catheter introducer sheath technique represents a valid adjunct in the endoscopic pediatric skull base surgery repertoire. It can help in avoiding inadvertent surgical traumas to the sinonasal structures, especially by residents and junior surgeons. This could potentially reduce postoperative nasal morbidity.

Reinforcing a Catheter-Associated Urinary Tract Infection (CAUTI) Bundle Compliance Decreases Overall Catheter Days and CAUTIs

BACKGROUND Catheter-associated urinary tract infections (CAUTI) are the most common type of healthcare-associated infection. The key risk factor for CAUTIs is prolonged indwelling catheter use, and therefore their use should be minimized when possible. The objectives of this initiative were to decrease CAUTIs by reinforcing bundle compliance and to decrease the use of indwelling catheters by utilizing more external catheters. METHODS Intervention began January 2017 when a bundle device compliance form with a daily catheter goal was introduced. This form ensured that proper procedures were followed, with a focus on the pericare process, with the most important step being the glove change after wiping the patient and prior to wiping the catheter. Bundle compliance was reviewed daily by unit managers and checked weekly by infection control, which resulted in an increase in bundle compliance, however the daily catheter goal was still not met. In January 2018 an external female catheter was introduced, and in June 2018 another type of external male?catheter was introduced in order to meet the daily catheter goal. RESULTS During the pre-intervention period (2016) a total of 32 CAUTIs were reported with 19,890 catheter days. Implementation of bundle compliance in 2017 led to a 9.3% reduction in CAUTIs and a 7.5% reduction in catheter days. Introduction of external catheters during 2018 further improved these numbers, leading to a total reduction of 59.3% in CAUTIs and 26.5% in catheter days compared to the pre-intervention period. CONCLUSIONS This initiative demonstrates that reinforcing bundle device rounds leads to moderate reductions in CAUTIs and catheter days. The initiative also showed that increased use of external catheters leads to even larger decreases in CAUTIs and catheter days. Implementing both of these measures met the goals for reductions in CAUTIs and catheter days and has led to an increase in patient safety.

Infection free midline catheter implementation at a community hospital (2 years)

To reduce excess central line use and provide an option for difficult venous access patients through the introduction of a midline catheter. Design included prospective monitoring of the implementation of a quality improvement project. The setting was a 576 bed, urban, community, nonprofit, Magnet recognized, level 3 trauma center serving primarily adult patients. Midline and peripherally inserted central catheters were inserted by a specialty nursing team; care and maintenance of all devices were provided by front line staff. Zero midline catheter infections were observed in the 24 months after implementation of the fixed length, power injectable device. Completion of therapy was 80%, the most frequently encountered complication was device dislodgement. Adoption of a vascular access nurse led midline catheter program, coupled with device selection algorithms expanded the ability to select the right device for the patient, while decreasing excess central line usage without additional increased risks to the patient.

Ultrasound-guided totally implantable venous access device through the right innominate vein in older patients is safe and reliable.

Ultrasound guidance has become the routine method for catheterization, dramatically reducing failure and complication rates for totally implantable venous access devices (TIVAD) placement. The aim of the present study was to report the safety and efficacy of ultrasound-guided right innominate vein TIVAD placement in older patients. Between September 2015 and September 2017, 55 older patients underwent right innominate vein TIVAD placement under ultrasound guidance. Intraoperative fluoroscopy was always carried out. The technical success rate and complications were recorded and retrospectively analyzed. The technical success rate was 100%. The success rate of the first puncture was 96.36% (53/55). The mean operation time was 28 ± 7 min (range 23-39 min), and the mean length of catheter introduction was 19.24 ± 2.65 cm (range 17-21 cm). The overall incidence of complications was 7.27% (4/55), including one arterial puncture with self-limiting hematoma, two cases of catheter-related infection and one case of fibrin sheath. No catheter malposition or catheter fracture was observed. At the time of this study, three TIVAD were pulled out unexpectedly, and 32 TIVAD are still in functional use. Ultrasound-guided puncture of the right innominate vein is safe and reliable to implant TIVAD, which can provide new options for older patients. Geriatr Gerontol Int 2019; 19: 218-221.

Efficacy and safety of ultrasound-guided cannulation via the right brachiocephalic vein in adult patients.

Central venous catheter (CVC) insertion is difficult to perform and is a high-risk operation; ultrasound (US)-guided cannulation helps increase the odds of success while reducing the associated complications. The internal jugular vein (IJV) and subclavian vein (SCV) are the most commonly sites in US-guided CVC insertion. In the present study, we evaluated the safety and efficacy of US-guided supraclavicular right brachiocephalic vein (BCV) cannulations in adult patients.Between January 2016 and December 2017, 428 adult patients requiring 536 CVC insertions underwent ultrasound-guided right BCV cannulation. The success rate and complications related to indwelling catheters were analyzed.The technical success rate was 98.32% (527/536). The procedure was successful at the first try in 511 cases (95.34%). The mean operation time was 13.26 ± 3.34 minutes. The mean length of catheter introduction was 13.57 ± 3.53 cm. Incidence of intraoperative complications was 2.61%. For 3 patients, the procedure was terminated due to pneumothorax (PNX), and in 11 arterial punctures there were self-limiting hematomas. The incidence of postprocedure complications was 5.97% (32/536). These complications included catheter-related infections (n = 18) and thromboses (n = 14). Insertion lasted an average of 10.68 ± 8.77 days.Supraclavicular, in-plane, US-guided cannulation of the right BCV is an effective and safe method for inserting central venous catheters in adult patients. It provides another option for catheter access to boost clinical performance in central venous catheterization.

Анатомическое обоснование выбора места пункции и введения центрального венозного катетера у кардиохирургических пациентов

Анатомическое обоснование выбора места пункции и введения центрального венозного катетера у кардиохирургических пациентов

Estudo prospectivo do bloqueio interscalênico periplexo guiado por ultrassom com cateter de infusão contínua para reparo artroscópico do manguito rotador e controle pós‐operatório da dor

ObjectiveThis trial investigated postoperative analgesia in arthroscopic rotator cuff repair surgery patients under general anesthesia, associated with ultrasound‐guided peri‐plexus interscalene brachial plexus block (US‐IBPB), and compared single injection to elastomeric pump continuous infusion of local anesthetics. Complications associated to both techniques are described. MethodsIn this prospective, quasi‐randomized controlled clinical trial, 68 adults scheduled for elective arthroscopic rotator cuff repair were assigned to receive Group 1 (G1=41) US‐IBPB with a 20mL injection of 0.5% peri‐plexus ropivacaine, introduction of catheter, injection of 20mL of 0.5% ropivacaine through continuous catheter infusion of local anesthetic by elastomeric pump (ropivacaine 0.2%, infusion of 5mL/h). In Group 2 (G2=27), US‐IBPB, with a single peri‐plexus injection of 40mL ropivacaine 0.5%. In both groups oral analgesics were prescribed, paracetamol 500mg associated to codeine 30mg for patients with VAS between 3 and 5, and also oxycodone 20mg for VAS≥6. The anesthesiology team was available through contact telephones and the patients received a table to complete in order to report pain intensity according to VAS, use of oral medication, and complications related to the catheter and pump, until the third postoperative day. ResultsThe intensity of pain was higher on second day after surgery than on days 1 and 3, in both groups confirmed by the ANOVA test (p=0.00006) Among the groups, G1 patients had lower pain intensity than G2, (p=0.000197). G2 patients presented greater pain intensity during all periods studied (days 1, 2, and 3) than G1 patients. Postoperatively, G2 patients had higher consumption of rescue analgesics, nausea, and vomiting (40.74%) vs. G1 (5%) and dizziness (25.92%). No patient with catheter and elastomeric pump (G1) had complications regarding its insertion and maintenance during postoperative period. ConclusionThe quality of analgesia for arthroscopic rotator cuff repair with peri‐plexus US‐IBPB and continuous infusion with elastomeric pump presented superior postoperative analgesia quality to single puncture IBPB on postoperative days 2 and 3, with lower consumption of rescue opioids in this period.

Clinical Signs of Basilar Skull Fracture and Their Predictive Value in Diagnosis of This Injury.

Although clinical signs for the diagnosis of basilar skull fracture (BSF) are ambiguous, they are widely used to make decisions on initial interventions involving trauma patients. We aimed to assess the performance of early and late (within 48 hr posttrauma) signs for BSF diagnosis and to verify the correlation between the presence of these signs and head injury severity. We conducted a prospectively designed follow-up study at a referral hospital for trauma care in Sao Paulo, Brazil, and performed structured observations for 48 hr post-blunt head injury in patients aged 12 years or older. The following signs of BSF were considered: raccoon eyes, Battle's sign, otorrhea, and rhinorrhea. Among the 136 enrolled patients (85.3% male; mean age 40 ± 21.4 years), 28 patients (20.6%) had BSF. The clinical signs for the early or late detection of BSF had low accuracy (55.9% vs. 43.4%), specificity (52.8% vs. 30.5%), and positive predictive value (25.7% vs. 27.1%). However, the presence of these signs was correlated to head injury severity, indicated by the Glasgow Coma Scale (p = .041) and Maximum Abbreviated Injury Scale-Head region (p = .002). In view of the low accuracy of these signs, resulting low clinical value of their presence, and their high sensitivity in the late stage, the study results contraindicate the value of BSF signs for making decisions about using the nasal route for the introduction of catheters and tubes in initial trauma care.

Non-surgical urologic management of neurogenic bladder after spinal cord injury.

To review the available data on non-surgical management for neurogenic bladder in patients with spinal cord injury (SCI). Before the introduction of urinary catheters and antibiotics, neurogenic bladder was one of the main culprits for death in those patients with SCI. Currently, the management of neurogenic bladder is focused in improving quality of life and preserving renal function. A literature review was performed and therapeutic management for neurogenic bladder was divided in six sections: (1) intermittent bladder catheterization; (2) indwelling catheters; (3) condom catheter drainage; (4) reflex voiding and bladder expression with Valsalva or Credé; (5) oral drug therapy of the spinal cord injured bladder; and (6) botulinum neurotoxin (BoNT). Intermittent catheterization is recommended as the preferable method for management of neurogenic bladder in patients with SCI based on limited high-quality data. However, this may not be feasible or available to all and other alternative options include condom catheter drainage or indwelling catheters such as urethral catheters or suprapubic tube, reflex voiding, and bladder expression with Valsalva or Credé. Non-invasive medical therapies are the key to improve incontinence, urodynamic parameters, and quality of life in this population. Botulinum neurotoxin has revolutionized the management of neurogenic bladder in the last two decades decreasing the need for reconstruction or diversion. The Joint SIU-ICUD (Société Internationale d'Urologie) (International Consultation on Urological Diseases) International Consultation reviewed the available presented data and provided specific conclusions and recommendations for each non-surgical urologic method to address neurogenic bladder after SCI.

Retained catheter during placement of dorsal root ganglion stimulator: a case report

Dorsal root ganglion (DRG) stimulation is a novel therapeutic option that is being increasingly utilized for patients with neuropathic pain. The potential complications during the placement of this device remain unknown. We describe a potential complication during DRG stimulator placement not previously reported in the literature. A 50-year-old male presented to the ED with lower back pain and right lower extremity radicular pain following placement of DRG stimulator at outside facility. A fragment of an introducer catheter was retained in the spinal canal and L2-L3 neural foramen. Patient underwent L2-L3 laminectomy for removal of the catheter without any complications. DRG stimulation is an effective option for intractable neuropathic pain, but the safety of the procedure and its long-term complications need to be further investigated.